Robotically assisted enhanced-view totally extraperitoneal repair (eTEP) of a recurrent umbilical hernia in a patient with peritoneal dialysis

Background: Abdominal wall hernias are frequent in patients with peritoneal dialysis. Guidelines recommend an open hernia repair with extraperitoneal mesh placement to avoid access to the abdominal cavity. Method: We performed a lateral docking robotically assisted enhanced-view totally extraperitoneal repair (eTEP) of a recurrent umbilical hernia with diastasis recti in a patient with peritoneal dialysis due to polycystic kidney disease. After suturing of the midline a 20 x 28 cm mesh was placed in the retrorectus space, covering the whole area of preparation while also overlapping all trocar sites. A drainage was left in the retrorectus space until the first session of PD did not sample any form of leakage. Result: Robotically assisted totally extraperitoneal hernia repair was feasible. The patient was able to continue peritoneal dialysis without intermittent hemodialysis. There was no leakage of the dialysate to the retrorectus space. Postoperative recovery was uneventful. 6 months after surgery the patient was free from pain and showed no signs of recurrence. Conclusion: Robotically assisted totally extraperitoneal hernia repair in patients with umbilical hernia and peritoneal dialysis could be a promising surgical technique to combine the advantages of minimally-invasive surgery with totally extraperitoneal mesh placement without access to the abdominal cavity.


Zusammenfassung
Hintergrund: Die Entwicklung einer Umbilicalhernie ist eine häufige Komplikation bei Patienten mit Peritonealdialyse. In den Leitlinien wird eine offene Hernioplastik mit extraperitonealer Netzeinlage empfohlen, ohne die Bauchhöhle zu eröffnen. Methoden: Wir versorgten die Rezidivnabelhernie eines Patienten mit Peritonealdialyse aufgrund einer polyzystischen Nierenerkrankung in robotisch-assistierter total extraperitonealer Technik mit lateralem Zugang. Nach Nahtrekonstruktion der Mittellinie wurde ein 20 x 28 cm großes Netz in den Retrorektalraum eingebracht, welches das gesamte Operationsgebiet inklusive aller Trokarzugänge abdeckte. Eine Drainage wurde im Netzlager belassen, bis die erste Peritonealdialyse keine Undichtigkeit der Peritonealhöhle zeigte. Ergebnis: Die Operation konnte erfolgreich in robotisch-assistierter, total extraperitonealer Technik durchgeführt werden. Die Peritonealdialyse konnte ohne intermittierende Hämodialyse fortgesetzt werden. Es zeigte sich kein Austritt von Dialysat in das Netzlager. Der perioperative Introduction • An appropriate mesh covering the whole epigastrium including the diastasis recti, the concomitant epigastric Peritoneal dialysis (PD) is frequently associated with ab-hernia as well as the trocar sites is obligatory. dominal wall hernias. Last year European Hernia Society In coherence with all the aforementioned, we decided (EHS) and American Hernia Society (AHS) published that an eTEP hernia repair, with an uncoated mesh placed guidelines, focusing on primary ventral hernia repair in in the retrorectal space, would be a suitable procedure. PD [1]. Open repair using onlay or preperitoneal mesh The right retrorectus space was entered with an optic placement without access to the peritoneal cavity was trocar. After blunt dissection with the camera the first recommended. Recently new extraperitoneal techniques DaVinci trocar was placed medially to the right semilunar with minimal invasive mesh placement in the retrorectal line. During endoscopic dissection two more trocars were space were established in hernia surgery. placed in the same line and the DaVinci X system was docked coming from the left side of the patient. Crossover

Case description
to the left retrorectal space was started with an incision of the right posterior rectus sheath laterally to the linea alba. The preperitoneal fat of the ligamentum falciforme We report a case of a robotically assisted enhanced-view was separated from the linea alba and the left rectus totally extraperitoneal hernia repair (eTEP) of a recurrent sheath was opened by an incision of the left posterior umbilical hernia, performed on a 43-year-old male patient rectus sheath. During crossover the hernias were reposiwith polycystic renal disease and PD. The patient tioned and a small opening of the peritoneum was supresented with a 2.5 x 2 cm recurrent umbilical hernia, tured. Dissection was proceeded in a lateral direction associated with a 3.5 cm diastasis recti and an additional towards the left semilunar line until the catheter covered epigastric hernia. The year before suture repair of aforeby a membrane of peritoneum could be visualised mentioned umbilical hernia was performed during the ( Figure 3, Figure 4). After suturing the diastasis recti implantation of the Tenckhoff catheter. An additional suand the two hernias with a resorbable barbed suture, a ture repair of another epigastric hernia between both 20 x 28 cm PVDF mesh was placed in the connected hernia localisations prior to implantation of the catheter retrorectal spaces, covering the whole area of preparation was reported. The patient had a BMI of 31 and no further while also overlapping all trocar sites. The operation was comorbidities other than epilepsy. Ultrasound examinacompleted placing a drain on top of the mesh and suturtions showed that the catheter was implanted close to ing of the skin. the umbilicus while passing the retrorectal space more Postoperatively PD was paused for 72 h. The drain recaudally ( Figure 1, Figure 2). Hence we concluded that a mained in place until the first session of PD did not retrorectal mesh placement with an overlap of at least sample any form of dialysate in the drain. Over 6 weeks 5 cm should be possible. a reduced amount of dialysate was used. Clinically and Regarding the necessity of regular peritoneal dialysis, we sonographically there were no signs of recurrence established following problems: 6 months after surgery whilst PD was able to be per-• Due to peritoneal dialysis abdominal pressure is eleformed with its preoperative parameters.
vated, resulting in a higher risk of hernia recurrence. • The anticipated area of mesh placement is compromised by the catheter crossing the abdominal wall Discussion while also increasing the risk of infection. • Intraperitoneal mesh placement is not favoured in In 2020 the EHS and AHS focused on the treatment of patients undergoing peritoneal dialysis. umbilical hernias occurring before or during PD in their • The peritoneal cavity is altered by PD in a way that guidelines for treatment of primary ventral hernias in rare makes it less accessible to surgery and is also accom-locations or special circumstances [1]. Various retrospecpanied by an increase in morbidity. tive case series have reported an occurrence rate of 3 to 15 percent of umbilical hernias in patients undergoing PD [2], [3], [4]. Umbilical hernia was the most common defect, followed by inguinal and epigastric hernias [2], [5]. The development of a hernia represents a frequent complication in PD, claiming up to 60.4% of all anatomical complications [6]. Risk factors are discussed controversially. However, the ones most frequently mentioned include: male gender, older age, multiparity, low body mass index, polycystic renal disease and prolonged PD duration [3], [4], [6], [7]. A few case series were published stating that simultaneous ventral hernia repair and peritoneal catheter placement seems to be a reliable and safe surgical procedure [2], [8]. The recently published guidelines are recommending the repair of a preexisting umbilical hernia before initiating PD [1]. However, strength of recommendation is weak and quality of evidence is low. So far there are neither RCTs nor any review articles on the treatment of hernias in PD patients. Thomas et al. [9] examined if watchful waiting is an appropriate option for PD patients with asymptomatic ventral hernias. Most of the hernias in this single center study were localized at the umbilicus (78%). The cumulative incidence of ventral hernia repair was 13% and 21% within 12 and 24 months after PD catheter application. The authors concluded that watchful waiting may be an acceptable option for selected patients with asymptomatic ventral hernias at the time of initial PD catheter placement.
3/5 Articles about management of ventral hernias occurring during PD are rare. There are one review and a few case series recommending tension free mesh repair to continue PD [3], [5], [10], [11]. Usually intermittent hemodialysis is not necessary [5]. AHS and EHS guidelines recommend an open extraperitoneal repair with placement of a preperitoneal or onlay mesh without access to the peritoneal cavity, in order to avoid port-site hernias, fluid leakage from port sites and intraperitoneal mesh placement [1]. This technique is safe and associated with low morbidity. Studies evaluating the role of laparoscopic hernia repair don't exist. Mesh augmentation is recom-mended due to the enlarged intra-abdominal pressure during PD. Martinez-Mier report a recurrence rate of 12% without implanting a mesh, compared with 0% in patients with mesh hernioplasty of 58 hernias in 50 patients under PD [11]. A novel approach using the eTEP technique for endoscopic retromuscular hernia repair [12] was evaluated by Belyansky et al. in 2017. A robotic modification of this technique was published in 2018 [13]. A robotically assisted eTEP hernia repair with retrorectal mesh placement in hernia patients undergoing PD has not been published so far. This approach could combine the advantages of 4/5 minimally invasive surgery without access to the peritoneal cavity with an extraperitoneal mesh overlapping all trocar sites. The excellent visibility and the possibility of accurate preparation offered by the robotic system could contribute to the continuation of PD and hence avoiding unnecessary hemodialysis. Due to the high incidence of umbilical hernias in patients undergoing PD, the insertion of the dialysis catheter should be performed with sufficient distance to the umbilicus in order to enable an overlapping mesh placement.

Conclusion
Robotic total extraperitoneal hernia repair in patients with umbilical hernia under peritoneal dialysis could be a promising surgical technique to combine the advantages of minimal-invasive surgery with totally extraperitoneal mesh placement without access to the abdominal cavity.